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Hello, everyone and welcome to our medical education event today. Um We have Nick Newton joining us today. He's gonna talk to us about emergency thoracotomy. Um What we're gonna do is as always, we're gonna have chat, we're gonna have questions in the chat. So please do pop all your questions in the chat. Nick can see those and he may or may not answer them as he's going along or he may leave them to the end depending on whether or not he can include that in how he, how his talk is going at the end. As always, your feedback form will be in your inbox and your certificate will be on your med account. Once you've filled out your feedback, please do complete the feedback. This is something this, it's just a way that we can value our speakers by just giving them feedback afterwards. Ok. So without any further ado I'm gonna to pass you over to Nick. All right. Thank you, Nick. Thank you, Sue and, and thank you to medal for the opportunity to do this talk. Um I can't see where everybody is from, but I'm told that there's quite an international audience today. So welcome. Um I'm in very sunny but a bit chilly Birmingham. And this is where I work. My name's Nick Newton. I am a consultant general surgeon with a specialist interest in trauma and emergency surgery. So I'm not a chest surgeon, although my background training is in upper G I, so I do chests for um esophagectomy and things, but this is predominantly focused on trauma and emergency and I'm very much of the opinion that we need resuscitative surgeons. So that's not necessarily a general specialist, but it's someone who is an expert at keeping a patient alive for the first hour, two hours of their, of their patient journey. So with that, let's get started that we, so just a word of caution before we get started, any care you provide as a surgeon or for that matter, as an an as an emergency medicine physician, as any sort of health care provider must be appropriate to the context and the system that you work in there is absolutely no point in turning up, opening someone's chest and realizing that your hospital has no blood, no intensive care, no scanner, no, no other resources. Um And similarly, there's no point turning up to a nice well appointed um hospital in a sort of capital city somewhere and doing something absolutely amazing and being turned and people turning around and saying, well, no, we have a cardiac surgeon that does that or a general surgeon or a whatever. So, think about the system that you work in, you must work within that system. Ok. That's really important. You cannot be a lone wolf, you cannot be, you cannot deviate from what is considered reasonable practice if you're not comfortable doing something that is new. But you think, oh, I'm good at something that's almost like that, then that is perfectly reasonable. It is probably better to do something you're good at and modify your technique than try doing something that you're not very good at, er, that you don't have any reserve of, of skill or knowledge to fall back on. Er, and absolutely, first do no harm. Clearly, the Hippocratic Oath still applies here, but first do no harm. But just remember that occasionally you will be the only person that can help someone and if a patient is going to die no matter what, then you can't make them any, any, any worse. So, there were some learning objectives in the advertising material for this talk. Um, but these are just those in highlighted form. We're going to talk about the indications for emergency thoracotomy or the ones that I believe we should be, are important. We're going to cover a little bit of technique. We're going to talk about the MDT, that's the multidisciplinary team approach to emergency Thoracotomy. We're going to touch on some anatomy but not in a great deal of detail. But importantly, I am not going to teach technical skills. Ok. You cannot learn how to do these procedures just by watching a video. Well, just by watching this presentation, you can certainly develop your skill by watching videos, you can know what skills you need by listening to this talk. Er, but the only way to do this, that the only way to develop your psychomotor skills and to know what works and what doesn't work is to do it, preferably not live, preferably er on er, some sort of model an or, or cadaver or animal model. Er, but we will talk about technical skills, but please don't think that I'm going to teach you those technical skills. I, so let's get uh let's get going. So just to touch on chest injuries, this is why we would typically open someone's chest and I cannot stress this enough, do the basics well. Ok, a TLS or whatever system that you have in, in where whatever part of the world you're doing. Ok, airway breathing, circulation and disability and in particular circulation and breathing um are vital. The vast majority of chest injuries can be managed with a simple intercostal drain. This is a key skill and it is a diagnostic test as well as a definitive intervention. This will fix about 90% of your chest injuries. You do not need a CT scan and you do not need a chest x-ray, you do not need point of care. Ultrasound. If you don't have any of those things, a chest drain and the the techniques and skills and knowledge and behavior that we talk about. And the rest of this talk is enough. However, clearly, if your system is set up to use a CT scanner to use MRI to use point of care. Ultrasound, work within your system. Really important. Bye. So the MDT approach opening the chest is a team activity. You need the airway secured, you need an assistant, you need some kit, you need blood, you need a means of getting blood into that patient. These patients are sick, we don't do it in the emergency setting. We're not doing a thoracotomy just for the fun of it. You're going to need blood, you're going to need time. You will need a degree of skill and we'll touch on how much skill think you need, but you definitely need knowledge. You'll need drugs and you'll need space and there are parts of the world, even in, even in the fairly developed, er, western world where not all of those things are available in particular, the skill and maybe to a lesser extent the space, but I've certainly worked in, in settings where blood has been our limiting factor. I've worked in settings where our skill set has been our limiting factor and sometimes time if you are dealing with a mass casualty situation and for a small regional hospital, somewhere fairly remote, a mass casualty could be two or three patients, er, you may not have the time to do these sort of things. Sometimes the situation will dictate your response. What does that mean if you've got multiple casualties? Is it appropriate to be opening someone's chest and placing that re and placing that burden on your limited resource? Are you a long way from somewhere that you could transfer the patient? And the simple fact of the matter is this patient is not going to survive that transfer. Ok. So it's, while your default setting should always be, what is best for the patient in front of me, sometimes what is best for the patient in front of me is dictated by the situation, not the patient, you've got to communicate between doctors, nurses, health care professionals, you cannot be doing this on your own. People will think they, they won't understand what you're doing if you don't explain and they won't know what their role is if you don't explain and communication with the family members is really, really important an emergency thoracotomy, especially if it's done in the emergency department, it is a brutal thing to watch, but it can be life saving. But if you don't communicate to this, to the family and engage with them, then you may find that you have very poor outcomes. So the initial steps, you will need some equipment in the bottom er, right of the er, of the picture we've got a jiggly saw, this is a wire saw with two handles. We've got some sort of big clip, er, it doesn't really matter what it is. This could be a Robert, it could be a seven inch, er, doesn't really matter but some sort of reasonable size surgical clip. Er, and even that's not essential, you need a knife that is essential. Er, and then typically in the UK, we use tough cut scissors, um, instead of the jiggly saw, it doesn't really matter. And in the life saving setting, these do not have to be sterile. It's nice if they are, but they don't have to be sterile. On the left is the incision. And the incision is fairly straightforward because if you can put in a chest drain and you can put a chest drain in the right place, then you can do a thoracotomy. That is the level of skill required. And the technique we'll talk about in a second is essentially as if you're gonna put a chest drain in on the right and on the left. And then you, where you've put those incisions, you join the dots slightly curving up to follow the curve of the ribs round the other side. And then you can either use the blades to cut all the way through the muscles or sometimes it's easier to use your tough cuts. The nice thing about the tough cuts is that they will cut through the sternum. But if you don't have tough cuts, if you've got smaller scissors or just the blade, then you can slide your um surgical clip with the curved tip pointing upwards behind the sternum, pick up your jiggly saw, pull back through and then use the jiggly saw to push through. And then the final piece of the puzzle is the FTO retractor, which I'm demonstrating at the top and you can put that in, you get both hands in, open it up, put the, put the retractor in er with these, with the er, with the crossbar lateral, not medial so that you can get full access. And that is your, that is the basic technique for your clan shelter on coom. So, um on the left, we've got another picture of, of the incision and then once you've got here here, they've got two fits in place. You can see that you've got the right lung, the left lung and then sitting in front of you will be the heart, the heart will be um concealed within um the pericardium and there might be quite a lot of fat outside that, so we'll need to open the pericardium and I'll talk about that in a second. Now, just at this stage, there can be a lot of fatty and connective tissue between the rear of the posterior border of the sternum demonstrated with the arrow at the top here and the mediastinum. And that can be quite, um it can be quite challenging for people that are not surgeons that don't know what they're looking at. There are no structures that are dangerous in there. You can cut through that with your shears. Um, to get down onto the, on to the pericardium, important bits of anatomy. These are not all of the bits of anatomy, but these are the things that I think it's really important to be aware of. If you're doing this for someone who is in extremist, the internal thoracic arteries won't sorry. The internal thoracic arteries probably won't bleed and they will sit either side of the sternum on the top and the bottom. However, if you are successful in your emergency, thoracotomy, they will bleed. So you do need to deal with them either when they start to bleed or if you see them when you're getting in or at the end, if you can't see them bleeding, but you can see where they are and just a simple suture to tie them off is absolutely fine when we're in the chest. These are the four important structures that I think it's really useful to know. Clearly. There's a heart, clearly, there's lungs, clearly, there's lots of big blood vessels. However, the phrenic nerves run laterally on the surface of the pericardium. And when you're opening your pericardium and you make your cut from top to bottom and then extend it laterally in an inverted T shape. You will see the phrenic nerve and you've got to make sure you don't cut it when you see it, you'll think, oh I'm not going to cut that. And then when you do it for real, and the adrenaline is running through your veins and everyone's looking at you to save this person's life. It's very easy to get carried away. So just be mindful of that. The aorta is really important and how we find the aorta for proximal control, which is one of the techniques we'll cover in a second is to slide your fingers around the posterior ribs up onto the vertebral body and then push and just press on the aorta. But that's where you're gonna find the aorta. That's really important. The most anterior of the major blood vessels of the heart, the major coronary arteries is the left anterior descending and that will be sitting broadly speaking right in front of you. And that's important because if you get stabbed in the front of the chest, the likelihood is that the injury will be near, hopefully not through the lad, but will be near to the lad. And so you'll have to come up with a repair technique that doesn't occlude the left anterior descending artery. If you put a big old suture wrapped all the way around that coronary artery, tight, it nice and tight to close a hole in the heart, the patient will have a cardiac, will have a coronary, they will have a um a myocardial infarction and they will probably die at that stage. So we've got to come up with a technique to deal with that. And then the final important structure is the inferior pulmonary ligament. So on the left hand, well on both sides, but particularly on the left, because there's only two lobes to the lung, the inferior pulmonary ligament tethers the medial border of the lung to the mediastinum. And it's quite difficult to get full access to the heart and to the chest and particularly to the aorta, it's not impossible, but it is tricky if the inferior pulmonary ligament is still intact. And the way to get this is to put your hand into the chest, wrap your fingers all the way around the lung and where your fingers meet at the back of the lung immediately just adjacent to the mediastinum. That is the inferior pulmonary ligament. You can slide your fingers down, find the inferior border, get some scissors and cut that again. When the adrenaline is rushing. When you're the hero that's opening the chest and saving this patient's life, you can get very carried away. The first structure you come to when you're cutting or dividing the inferior pulmonary ligament as you go north is the pulmonary vein. And if you take your tough cuts or your scissors and you cut the pulmonary vein, that is probably a non survivable iatrogenic injury. So you're much better off not going as far as you can, er, and er, and just leaving yourself a little bit of safety margin. If you're not confident, then risking that damage. But that's just a, just a really important comment. Um But I did so when it comes to operating and when it comes to doing the emergency thoracotomy, the technical skills that you need are fairly limited. If you have ever done a laparotomy, a thoracotomy. If you ever have cut into um human skin and tissue in a surgical way, then you can do a thoracotomy. What is challenging is knowing when to do the thoracotomy and that's where this high level decision making comes in. Do we do it in the emergency department in recess? Do we do it on the side of the road? Do we get the patient to the operating theater? Am I the best person to do it or is the patient? Well enough that I can call someone with more expertise. Do I have the resources to manage this patient? Because the moment I open their chest, assuming they survive, they will start eating through my drugs, my blood, my people and my bed spaces. Ok. If you are in a very resource rich environment, that's really of no consequence. If you are in a resource limited environment or if you're far from further help or resupply, then that's a really significant thing to think about opening the chest is not something you can do on your own, even if you are on your own. Let's say you're a prehospital provider and you are on the side of the road with just you and a paramedic and maybe a policeman and maybe a police officer, maybe some, some standards you, you will be doing that within a system that supports you and you've got to make sure that that system, that teamwork, that collaboration will support whatever action you're taking. And in the ideal world, you have practiced this before the patient even exists. You have talked about what will happen if I need to open a chest? Do I do it in recess? Do I do it in theater? Am I the person that's going to do it? Who is going to tell me to do it? Is it my judgment as the surgeon or is it the trauma team leaders judgment? Is it the anesthetists judgment? Does everybody in the room know that there is a set series of criteria and you just follow the criteria. It doesn't really matter so long as you've thought about all of those things, right? If, if you think so, the three indications that I have for an emergency thoracotomy are these resuscitation? And we've touched on that. That's your clamshell thoracotomy performed in the recess er area or in your emergency department or sometimes in your operating theater if you've managed to get them there quickly. But that is for someone who has arrested or is peri arrests who needs immediate life saving treatment. The next indication is massive hemorrhage. Ok. And we'll talk about that in a second. And then the final indication that I have for opening the chest is proximal control of the aorta. So that is not a chest operation, that is an abdominal or a pelvic operation. And again, depending on your system, depending on your set up, depending on what you've decided it could even be opening the chest for postpartum hemorrhage because opening the chest is easy, often easier than doing a laparotomy if you don't have the right kit. Uh So before we move on, in af patients, how critical is it to get treatment history? See if there are anticoagulants, treatment, hence their bleeding risks. So that, that's, that's a really important question. It depends entirely on how um how critical the time is. If you are doing a resuscitative thoracotomy, then you don't care what blood thinners they're on. You don't care what drugs they're taking. But I will tell you that if you're doing a resuscitative thoracotomy on someone who is old enough to need to be on blood thinners because of af the likelihood of them surviving is very, very low, probably less than 1%. Um very, very important if you're contemplating doing a thoracotomy for someone with massive hemorrhage because that develops over time giving them the reversal agents, whatever those might be is critical. And there are certainly circumstances. So London Hems, for instance, has a protocol for empirically giving reversal agent for anyone who is on Warfarin um there are reversal agents for the newer um directoral acting anticoagulants, the Rivaroxaban, the, the things, but some of those agents are critically are, are, are, are cripplingly expensive. So you've got to work. This is a really good example of working within your system. OK. That's a really good question though, especially for the massive hemorrhage, which we'll talk about in a second. So, resuscitation, my view is that this is for patients in extremists. This is patients who have either er arrested or are about to arrest. And how long you leave it before you let them arrest is very much a communication between the team leader, the Anestis, maybe the prehospital provider and yourself. It is resource intensive even in the best settings, outcomes are poor with mortality greater than 95% for most series. With the exception of one or two very, very specific er series looking at er single stab wounds to the right ventricle where they have an output and they have Taminol that is released outside of cardiac tamponade from penetrating trauma. The outcomes from resus thoracotomy are poor, not zero but poor. It must be a coordinated approach. If you take nothing else away from this talk, it is all about the coordinated approach. This patient if they live, is going to theater and is going to intensive care. The resuscitative thoracotomy if it is successful is the start of the journey, not the end. And that's really, really important if you don't not have an exit strategy, once you've opened someone's chest, then you probably shouldn't be doing it. So I, I, I've broken down the resus thoracotomy into what I consider to be the four key stages. And each of these key stages treats a different life threatening pathology. So stage one is to do simple, bilateral thoracostomy. So that's as if you're putting in a chest drain, slightly bigger cut, big cuts, left and right as if you're putting in a chest drain, put your finger in and that relieves your tension pneumothorax. So if you've got a tension pneumothorax and you've arrested, you have treated that. So that is, that is condition number one, condition, number two. OK? Or, or the next stage is to extend your thoracostomy into a clam shell. And this gives you really, really good. One might even say unparalleled access to the contents of the media stum, ok. And this allows you to do the next two things that the patient is likely to have arrested from it, lets you open the pericardium and relieve a tamponade and it lets you manually compress the aorta. So in my hands, the resuscitative thoracotomy goes bilateral thoracostomy, open, convert to a clam shell, open the pericardium. If there is an injury, put my finger on it, er compress the aorta with my other hand and then stop. And I will say in a loud, clear voice and I am a six ft two white public school educated military officer. So when I say in a loud clear voice, basically everyone in the hospital can hear me. OK? I will say resuscitative thoracotomy, complete pericardium is open aorta is occluded. And then you stop, you talk to your team, you find out what's going on and you plan the next stage. This is not the end of the journey. This is the start of a treatment. What's the max time for aorta? Cross clamping? Um So because you're cross clamping in the chest, OK, you're taking out the liver, you're taking out all of the small bowel, you're taking out the kidneys. So you really don't have much more than 20 minutes or so. It's a bit like pin pringle maneuver on. This is essentially buys you time to do to move the patient to an operating theater, get into the abdomen and then get better control somewhere within the abdomen. Ok. So it is not something you can leave on. It is definitely a temporizing measure and it may be that your anesthetist says, right? OK. We've been on 10, 15 minutes. Can you, we've done good resuscitation. Can you let the pressure off the aorta a little bit, let a bit of blood out and then, you know, manage that. And that's quite common. But yeah, no more than about 15 or 20 minutes because you're rendering the entire contents of the abdomen ischemic by clamping the aorta we can. So what Next, we're going to talk about repairing a cardiac injury. We're going to talk about putting a clamp on the aorta. Some of the books and some of the teaching will say the clamp on the aorta is part of your resus thoracotomy. Now, I have done this, I've read and talked to people who say they can do this very quickly. But in my hands, this procedure takes two or three minutes where and requires some very specific equipment which we generally don't keep in the, in the resuscitation department. Whereas putting your hand on it is easy, quick, cheap, everyone's got a hand, not everyone's got a hand, but everyone who's doing this operation hopefully has a hand, preferably two of them. And by pressing on the aorta, you are not going to damage the esophagus and you're not going to damage the um blood supply to the spine. And because if you damage the blood supply to the spine, then you can run to the patient, um, quadriplegic or paraplegic depending on what level you're at. Ok. And if you damage the aorta at the esophagus, that's really bad. So you can clamp the aorta to free up a pair of hands, but that's not a quick procedure. Call for help. So if you're in a setting where you can call for help, this is a good time. Move to the operating theater. If you think you've got an output, if you've got more work to do do not do it in recess. And think about futility early. Don't waste blood resource capacity in someone who is not going to do. If you can see that this patient is so badly injured that you cannot fix them quickly, then have that conversation early about futility. So the second indication is massive hemothorax. Now, there are many different, there are many definitions that you can read in the books and you can broadly pick one that you like, whether that's more than 1500 mils in one go, whether that's more than 2000 mils coming out of your chest drone in one go. Whether that's 400 mils an hour for four hours, 200 mils an hour, two hours over four hours, it's usually not subtle because the patient will have a lot of blood coming out of their chest and they won't respond to blood resuscitation. So you put blood in and it comes out the chest drain. So the exact numbers are, are not, you know, usually as helpful as actually having an appreciation of the injury burden and what's happening to the patient. You do need a local protocol so that everyone agrees with you. It's not just the Nick Newton. Oh yeah, they've got a liter of blood out. I'm gonna open their chest cos I like doing that. It's got to be done as part of your team. Again, if you take nothing more from this, this is a team game there is AAA slight philosophical debate. If you go in very early with surgery to avoid blood loss, you might be able to give less blood, be aggressive, but you will probably over call surgery, you'll probably overuse surgery and blood is not the only resource that you need if you are very reluctant to do surgery, which is very, that's perfectly fine because you don't want to put the burden of the morbidity or the resource use. You know that those are significant considerations. Just remember that you will use more blood, probably if you lose blood, you will use blood bleeding continues until you turn the tap off and related to the futility. Comment from the previous slide, you may commit to surgery and find that there's nothing to repair. So if you open open the chest and find a big hematoma around the root of the aorta, and you don't have the ability to put someone on bypass and you go in to explore that and suddenly you've got uncontrolled bleeding from the root of the aorta, that patient is not going to survive. And and that's obviously sad in the context of that patient, but it's perfectly reasonable within the context of a system that is not set up to deal with that patients do die. This is a really significant injury at operation. So the definitive techniques we're going to talk about some of which I will show you in a little bit more detail. And that is the cardiac repair and the lung tractotomy. And uh the proximal control of the aorta will talk about proximal control of the great vessels as well. Um But just to touch on packing an intercostal small vessel injury repair, people bleed to death from damage to the intercostal vessels. People certainly bleed to the point of needing surgery from damage to the intercostal vessels from having a chest drin put in. So these are injuries that can generate massive hemothorax, they can need a, a thoracotomy to repair them. So don't forget those injuries and sometimes they are quite impressive but really easy to repair. So, if you have a penetrating injury to the back that causes a little nick er, to the aig vein, for instance, that will bleed and bleed and bleed, but it's really quite straight forward to, to fix. Uh, and, and carries a relatively low longterm morbidity if you have uh, bleeding coming and you can't see where it is, um, or it's not easy to repair in exactly the same way as we do within the abdomen or within a wound, we can pack that put direct pressure and oftentimes that is all you need. This won't work if you've got a big hole in the aorta. But if you've got a big hole in the aorta and you don't have bypass or skills to repair that, then they're probably not going to survive. But if you've got little bits of bleeding or torn, um, bridging vessels or something like that. Packing is really effective. I'm not going to talk more about those. We're going to focus on cardiac repair, lung tractotomy and proximal control of the aorta. Mhm. That so there are lots of different ways of repairing holes in the heart. I use the same technique every time because I am not a cardiac surgeon. If I'm doing this, it's because the patient's life is in danger. I don't do this electively. So I want to limit the cognitive workload, the cognitive burden that I have by not having to think about which technique I'm going to use. But by thinking about all the other things I need to think about. So I do a buttressed mattress suture. I use pericardium as a pledget and I'll show you a picture of what this means in a second and in for preference, I will use a 30 proline suture on a round bodied needle. However, I'm a very precious general surgeon and I like things to be just so. So if you hand me anything, I'll use it. OK? But if you've got a choice, ReoPro on a round bodied needle is a good choice. You can use synthetic pledgets. Uh You don't need to use pledgets. Uh But that is how I do it. OK? Because everybody's got pericardium and it's easy. So just ignore. So I've got my arrow here. Um uh So um I'll explain what lung tractotomy means when we, when we come on to that bit, that'll be the next slide. So the most important um bit for the picture on the left with the hand is not this suture, it's this finger. That is your first means of controlling um bleeding from the heart. It's to put a finger on and just stop, talk to your team plan what you're going to do and then these are various injuries in various ways. So here is a Satinsky, a side biting clamp and a continuous repair of the aorta. Here is a simple repair. Um Here is a mattress repair and I talked about avoiding the left anterior descending artery. And you can see that this mattress repair runs under closes, this injury that runs adjacent to the left anterior descending and closes it. Uh And then this for me is the most important picture and this is really the technique that I want you to take away. So here we have a mattress suture exactly as you've been taught to close the skin. Exactly as you've been taught in basic surgical skills. Nothing fancy. And these little blue dots, these little blue plugs are pledgets. Now, these are probably synthetic pledgets, which is absolutely fine. But what if you don't have a pledget synthetic or otherwise everybody's got pericardium and you can use little bits of pericardium here to um as a pledge it. And that's a really, really reasonable way of doing it, this is how I would repair all cardiac injuries wherever they are because I'm good at it and it's what I'm used to doing and I'm not a cardiac surgeon. So I don't have a depth of experience and a breadth of skills to be able to pick and choose what I do that. So, um Hala Abraham asked what, what a lung tractotomy is. So we're going to talk about that next. So if you have a penetrating injury to the lung, there will be bleeding and there will be air coming out from the bottom of that injury. And you need to be able to control that bleeding and that air leak, you might also have a bit of devitalized lung. So a little tag, you know, the inferior portion of the lower lobe might just be mashed up and you and might be bleeding. So for a tractotomy, which I'll show you a picture of in a second, it will become clear. You need either some non crushing bowel clamps, a linear stapler and you definitely need some more of my favorite ReoPro or four aro whatever you have. So let's look at a picture. So the track is the injury through the lung, ok? And in the picture on the left, you can see this injury and you can see this sur surgical stapler has been passed all the way through the injury. The tract oy ot toy means cutting open is where if you're using a stapler, you fire that stapler. And you can imagine that where these clamps are in the picture on the right, you'll have rows of staples and you'll have the tract, the wound track will be open. And you can see where this surgeon has started tying off little air vessels and little blood vessels. And there's um, the pink froy um blood that demonstrates an air leak. And this surgeon is using some three a pro probably or 40 proline to seal these off. If you haven't got a stapler, you can do what they've done on the right, which is to put your noncrushing bowel clamps through that injury in the lung, put two in, cut in between them, open it up, repair any bleeding and air leaks in the base of the track. And then you can do some sort of continuous suture to secure this cut edge of lung before taking the track off. Like I said, at the very beginning, I am not going to teach you surgical techniques. I'm going to show you some surgical techniques. But this is the sort of technique that you could easily practice on either um animal lungs or human cadaveric tissue in the context of a course or in the context of of tissue training. Ok. And this is a really nice technique to practice. Yes, it's, it's easier and quicker if you've got a surgical stapler, but you can do it with simple instruments. So the final um technique we're going to talk about is proximal control. So it's really important, not just to blind clamp the aorta. OK. The first thing that will happen is that you'll damage some of the um spinal arteries. The next thing that will happen is that you'll damage the esophagus. And the third thing that will happen if you haven't taken the pleura is that your clamp will slide off and it will not achieve what you want to do. So you've got to open the pleura, you can use scissors for this. It is quite a long way back and can be difficult to see but get down to it under direct vision and open the pleura. And then once the pleura is open, I just get my finger in and just gently dissect all the way round the back of the, of the aorta with my finger. And then I can put my finger all the way round, divide the pleura over the top of my finger again so that I can get all the way round and then I can place a non cushing bowel clamp or if I've got one, an aortic clamp onto the aorta. And I know that I've done that under direct vision. I've done it slowly and I've done it carefully and, and it is safe. OK? And we'll see a picture of this. Now, I'm afraid the pictures a bit blurry. It doesn't project terribly well. Um But you can see that we've got the clamp across the aorta. You can see how close the esophagus is sitting, we're retracting the lung out of the way. And you can sort of make out that we've divided the pleura, which is this slightly paler pink compared to the slightly darker pink bit. And then you, you don't see the vertebra beautifully like this, but this is where the vertebra sit and you can definitely feel them under your, under your hands in my hands. This is part of abdominal surgery, ok? Because the only bleeding that you're going to control here is within the abdomen. But for a lot of a lot of situations, this is a technically easier procedure than trying to get a clamp onto the aorta within the abdomen. Ok. So this is a really safe straightforward get out of gel free card if you're struggling to control a um arterial bleeding within the abdomen. So the second bit of proximal control is the great vessels that run into the neck and the arms, the three that you've got to worry about within the chest are the ominous artery which very quickly splits into the right common carotid and the right subclavian. Then you've got the left common carotid and finally the left subclavian. And here a bit of anatomy is useful. It's to remember that the aorta does not exist in two dimensions. It goes up, it goes posteriorly and then it dives deep into the into the upper medial stum before curling down in the arch of the aorta and ending up in its position in the, in the, er, er, posterior mediastinum. So this left subclavian artery is really, quite posterior and it can be very, very difficult to access. If you need to get, it's not impossible, but it's not something you want to be doing in a hurry, it's not something you want to be doing in a, if you're rushing. So it's very much something you want to be doing as part of a controlled procedure, er, to deal with, er, more disc or bleeding, er, for instance, penetrating injury to the shoulder, it's ok. So we've said this before and this is probably the second big take home message. Proximal control is only the beginning. It's the start of your journey, not the end you've got to do, do know what you're going to do next. You've got to plan what you're going to do, communicate with your anesthetist because the moment you start clamping things, you're gonna change the dynamic circulation and at some point you're gonna need to take the clamp off, that is going to change things again. You might cause bleeding when you take the clamp off. So you've got to be prepared with your anesthetist to have blood in theater to have a plan for what you're gonna do. Communicate your plan and then just get on with it unless you're waiting for help and that is your plan, just get on with it and always think is my plan going to plan or do I need to change? Have I got the resources? Have I, if you've run out of blood and you know that some, you're gonna do something that's going to cause another three or four units of blood loss, then you're in trouble. Have you got the skill to deal with the problem? I am reasonably experienced. I for these sort of injuries, I will always call in a fellow consultant colleague to help me. Ok. And do you have the time? Have you got another three or four patients waiting for simpler interventions that you could do? And you actually turn around and say, look, I've clamp the aorta, but I've got nothing to offer this patient. Now, there's nothing more I can do. Ok. Constantly reassessing, constantly communicating. It's a, it's a bit spin ball. So we've managed to solve the problem. We've got to the end of this stage of the operation. What do we do? So these anyone whose chest you've opened and whose pericardium you've opened needs five drains, the apex, left and right, the base, left and right, and a pericardial drain. We don't close the pericardium. If you are a cardiac surgeon and you do, that's absolutely fine. I am not a cardiac surgeon. I am a trauma surgeon and I would always leave the pericardium open because there may be more bleeding and you may run into the problems of, um, pericarditis or Dressler syndrome. Um, and so these are, these are things we're doing a simple operation to save the patient's life. I close, um, the, bring the two sides of the trauma thoracotomy together with something like a 55 eon. So a big, big stitch just wrapped around the ribs just to approximate the ribs. And then I'll use, I typically close my abdomens with 20 pds. Um but you can use er Luke one P DS. You can use anything really but an absorbable suture to close the fascial layers of the chest and that will bring it all together. You do not need to put er sutures through the sternum. However, people do and if that is your practice, that's absolutely fine. And then it's perfectly reasonable to close the skin with stitches. It is perfectly reasonable to close the skin with staples. It's perfectly reasonable to leave the skin open if that's what you want to do. Ok. But you do need to do if you can close the chest, having done something definitive, it does make waking the patient up and caring and nursing for them going forwards. Much, much easier. Take, be good at the basics, keep your patient warm, monitor them in as far as you're able to. Now, for some parts of the world monitoring is extremely limited. Other parts of the world monitoring is extremely aggressive and invasive, but you've got to monitor at probably at the least, make sure that they have a catheter, make sure that they have a regular heart rate, BP. If you've got an oxygen saturation monitor, that's great. But if you don't look at the patient, do they feel warm? What's their respiratory rate? Heart rate, BP. And if you do have the ability to do bloods, then take regular blood tests. All of these patients should have a shot of antibiotics. If you're within three hours of injury, which you probably will be, then these patients should have their tranexamic acid following whatever system you use in your organization. Uh If they have a penetrating injury, always consider tetanus or tetanus immunoglobulin and make sure that they're on their routine medications. Doctor addie asked about patients on anticoagulation. Uh clearly, if you've reversed anticoagulation and someone is at high risk of having a thromboembolic event before their injury, they will be even higher risk of a thromboembolic event afterwards. But they will also probably be coagulopathic. So you've got to balance when you want to restart routine anticoagulant medications. Do they need their BP medications? Is statins really the most important thing at the moment and heaven forbid, are they on clopidogrel? And you know, do you need to do anything about that? So, in summary, we've talked about um the three indications for emergency thoracotomy. Um We haven't gone into the anatomy in detail, but I've pointed out some particularly important elements that I always think about when I'm doing this operation, I've stressed time and again, the MDT approach, the multidisciplinary team approach and the importance of communication. Within that MDT, we've talked about some of the techniques that can be used once you've opened someone's chest and I've talked about some of the technical skills. I please do not walk away from this talk thinking that you can do these but just know that these are the technical skills that it would be sensible to achieve to learn. If you feel that you're going to be doing emergency thoracotomy. And there are many cadaveric courses, animal based courses and also some really nice videos which I will talk about in in the next in a couple of slides time that can help you develop and hone your technical skills. So in conclusion, do the basics. Well, the vast majority of your patients will do well with a simple chest train, do your basic surgical skills well, and look after the holistic needs of the patient first, do no harm. But if your patient is going to die, then there is no danger and no one will criticize you for trying to help and you must must, must work within your system, not outside of it. My final slide is just some resources that I think this audience might really benefit from. So the first one is my absolute favorite. Top knife is a textbook. It's quite old now. But nothing that it teaches is out of date. It's a very easy to read book. It's quite small, it's lightweight. It's small enough that it will fit in a cargo trouser pocket or in the top of your rucksack or in your handbag or in your, er, day sac or just live, you know, on your desk, wherever you work, it's a great, great book and it will teach you all of the techniques, er, and all of the skills that you would need touch surgery app. I'm not sponsored by them. I don't have any, any skin in that particular game, but this is an app that you can download onto an ipad, a computer or a phone that takes you through the cognitive steps of procedures. So it's not going to give you the psychomotor training particularly, but it will teach you the cognitive elements of the practical skills and there is an emergency thoracotomy, um, session on the touch surgery app on my phone and you can get it. Um, for ipads, er, other, other tablets exist and for laptops is the anatomy learning 3d anatomy app. I really like it. It's quite cheap. Er, it's really nice, it just shows you can decide what level of anatomy you want to see what vessels, what structures, whether you want the bones and the muscles. And it can be really helpful again for the cognitive understanding of the procedure that you're doing. Er, giving a shout out to Medal. Thank you very much for supporting my talk today. But Medal have some excellent resources, youtube have some excellent resources but just be careful that youtube is not curated. So you cannot guarantee that what you see on youtube, unless it's branded from a reputable organization, you don't know that it's, it's um, er, accurate, er, and then finally there's an organization called Behind the Knife, er, and they do podcasts and videos, Er, and, er, again, I'm not supporting them particularly but I really like how they approach, er, their, their, um, er, their subject matter. Er, and, er, so I would, I would really support, support, er, having a look at that, basically look at things and see what works for you is what I would say. Er, and with that, um, I've been talking for, er, just under 50 minutes. Er, and I've got to the end of my talk. Thank you for listening and I hope you found it informative. Thank you, Nick. Thank you. Um, does anyone have any questions that they want to pop in the chat? Um, brilliant. So we do have behind the knife on the platform. They have like, um, the really bite size, er, little, er, like five minutes or something, isn't it to learn how to do something right handed or left handed or not? Those kind of things. We do have a lot of their videos. Another organization that I was gonna mention is B bas there on a Monday night and it's David o'regan. I don't know if you know him, Nick, he's from, um, he's from the Royal College of Surgeons in Edinburgh and he does things that are just amazing. He'll like, he'll like suture a banana on, you know, so that everyone can see and, and he's very much into posture and making sure that the basics are correct, like you were saying, make sure the basics are all right. And then the rest will all fit into place, sort of thing, very firm on his basics. You know, cos he thinks that obviously if you're a bit of a butcher, then you're gonna cause additional damage, aren't you? When you not that people are butchers? Sorry. So does anyone have any other questions at all? You've got lots of thank you by the looks of things. So, um I think yes, people have gone to the B bath. It is a great course. It really is. Anyway, if that's it, if nobody else has any questions, that is great. And um like I said, feedback form will be in, please. Could you repeat the last organization you met? Oh, was that the one that I mentioned or did you mention? And one from Edinburgh too? No, no, I didn't. I think that's the black belt Surgical Skills one. Yeah, it's, it's on, if you scroll up the chart, you'll see a black belt Academy of Surgical Skills. His name is David o'regan and he, he is from the Royal College of Surgeons of Edinburgh and he is really passionate about your skills and he's passionate about other people learning anywhere they are in the world. You know, he's just brilliant. Anyway, Nick, thank you ever so much. We're going to say goodbye now to our delegates. So thank you very much. Yes, you can watch your recording on Medal. I just need to pop it up. Alright everyone. Thank you so much. Alright.